Inspection Reports for Lakeview Nursing Center

The State Agency conducted a follow-up revisit at the facility on 11/17/2025 related to an annual recertification survey conducted from 9/15/2025 through 9/18/2025.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 10/15/2025.

The State Agency conducted a follow-up revisit at the facility on 11/17/25 related to an annual recertification survey conducted from 9/15/25 through 9/18/25.

The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and recommends the facility be placed back in compliance effective 10/15/25.

The survey was conducted to assess compliance with the Life Safety Code (LSC) and emergency preparedness requirements at Lakeview Nursing Center.

The facility met all applicable provisions of the 2012 Edition of the Life Safety Code with no deficiencies cited. Additionally, the facility met all federal, state, and local emergency preparedness requirements with no deficiencies.

The State Agency conducted an annual recertification survey at Lakeview Nursing Center from 9/15/2025 to 9/18/2025 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with licensure requirements due to failure to post oxygen cautionary signage on a resident's door where oxygen was in use, and failure to provide an alternative meal choice of equal nutritive value for residents.

The State Agency conducted an annual recertification survey at the facility from 9/15/2025 through 9/18/2025 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with requirements and cited for deficiencies related to accident hazards (oxygen signage not posted), medication storage and labeling (medications stored at bedside without assessment for safe self-administration), and resident food preferences (failure to provide alternative meal choices of equal nutritive value).

The State Agency conducted a Complaint Investigation at the facility related to timely assessing and addressing a resident’s complaints of abdominal pain and distension.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Complaint Investigation MS #2580452 and MS #2580451 related to timely assessment and addressing of a resident’s complaints of abdominal pain and distension. No deficiencies were found.

The State Agency conducted a Complaint Investigation related to timely assessing and addressing a resident’s complaints of abdominal pain and distension.

The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.

Complaint Investigation MS #2580452 and MS #2580451 related to timely assessment and addressing of resident complaints; no deficiencies were cited.

The State Agency conducted a complaint investigation related to accidents/falls at the facility from 2025-07-18 through 2025-07-21.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Complaint Investigation MS #472744 was related to accidents/falls and was found to be unsubstantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation related to accidents/falls at the facility from 2025-07-18 through 2025-07-21.

The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.

Complaint Investigation MS #472744 was related to accidents/falls and was found to be unsubstantiated with no deficiencies cited.

The State Agency conducted a Complaint Investigation related to accidents/falls at the facility from 2025-07-18 through 2025-07-21.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. There were no deficiencies cited.

Complaint Investigation MS #472744 was related to accidents/falls and was found to be unsubstantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation related to accidents/falls at the facility from 7/18/2025 through 7/21/2025.

The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.

Complaint Investigation MS #472744 was related to accidents/falls and was found to be unsubstantiated as no deficiencies were cited.

The State Agency conducted a follow-up revisit at the facility on 5/21/25 related to the annual recertification that was conducted on 3/30/25 through 4/2/25.

The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 5/13/25.

The State Agency conducted a follow-up revisit at the facility on 5/21/25 related to the annual recertification that was conducted on 3/30/25 through 4/2/25.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 5/13/25.

The State Agency conducted a desk review on 05/13/25 of information related to the annual survey conducted on 04/02/25 to verify correction of previously identified deficient practices.

The facility provided information confirming that measures were put in place to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 05/13/25.

The State Agency conducted complaint investigations related to resident abuse, resident safety, injury of unknown origin, and improper discharge at the facility from May 5, 2025 through May 6, 2025.

No deficiencies were cited related to the complaint investigations; however, the facility remains out of compliance with state licensure requirements due to deficiencies cited on the April 2, 2025 survey.

Complaint investigations MS #28807, MS #28794, MS #28702, MS #28693, and MS #28833 were conducted. MS #28807, MS #28693, and MS #28702 were related to resident abuse. MS #28794 was related to resident abuse, resident safety, and injury of unknown origin. MS #28833 was regarding an improper discharge. No deficiencies were cited related to these complaints.

The State Agency conducted complaint investigations related to resident abuse, resident safety, injury of unknown origin, and improper discharge at the facility from May 5, 2025 through May 6, 2025.

No deficiencies were cited related to the complaint investigations; however, the facility remains out of compliance due to deficiencies cited in a prior survey dated April 2, 2025.

Complaint investigations MS #28807, MS #28794, MS #28702, MS #28693, and MS #28833 were conducted. MS #28807, MS #28693, and MS #28702 were related to resident abuse. MS #28794 was related to resident abuse, resident safety, and injury of unknown origin. MS #28833 was regarding an improper discharge. No deficiencies were cited related to these complaints.

The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) requirements, specifically focusing on the fire alarm system testing and maintenance.

The facility failed to provide current year (2025) documentation of annual and sensitivity inspection of the fire alarm system, affecting the entire facility. The deficiency was acknowledged by the Administrator and Maintenance Supervisor during the exit interview.

The State Agency conducted an annual recertification survey at the facility from 03/30/2025 through 04/02/2025 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with multiple requirements including maintaining a clean, comfortable, homelike environment, implementing comprehensive care plans, ensuring safe resident environments, food safety, accurate staffing reporting, quality assurance program effectiveness, and timely immunizations.

The State Agency conducted an annual recertification survey at the facility from 03/30/2025 through 04/02/2025 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with multiple requirements including maintaining a safe, clean, comfortable, homelike environment, completing required assessments and care plans, ensuring proper food safety, accurate staffing data reporting, and immunization administration. Deficiencies were cited in environmental cleanliness, care planning, accident prevention, food handling, staffing data accuracy, quality assurance monitoring, and immunization timeliness.

The inspection was conducted to assess compliance with the Life Safety Code, specifically focusing on the maintenance and inspection of the fire alarm system in the facility.

The facility failed to provide documentation of the 2025 annual and sensitivity inspection of the fire alarm system, resulting in a deficiency affecting the entire facility. The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview.

The State Agency conducted a Complaint Investigation (CI), MS #27270, related to resident safety, safety issues, and physical environment at the facility.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Complaint Investigation MS #27270 was investigated related to resident safety, safety issues, and physical environment. The complaint was not substantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation (CI), MS #27270, related to resident safety, safety issues, and physical environment at the facility from 1/30/25 through 1/31/25.

The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the complaint investigation.

Complaint Investigation MS #27270 was related to resident safety, safety issues, and physical environment; no deficiencies were found.

The State Agency conducted a desk review of information related to a complaint survey completed on 2024-07-02 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2024-08-13.

The visit was related to a complaint survey completed on 2024-07-02. The facility was found to be in compliance based on the desk review.

The State Agency conducted a desk review related to a complaint survey completed on 2024-07-02 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficiencies and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2024-08-13.

The visit was related to a complaint survey completed on 2024-07-02. The facility's corrective actions were reviewed and found satisfactory, leading to a recommendation for compliance restoration.

The State Agency conducted a Complaint Investigation (CI), MS#25586, related to infection control regarding hand hygiene at the facility on 07/02/2024.

The facility failed to ensure infection control measures were consistently implemented to prevent infection transmission, specifically observing a Certified Nursing Assistant (CNA) carrying a soiled brief in gloved hands without hand hygiene before entering the soiled utility room. The facility policies on hand hygiene and perineal care were reviewed and found not followed during the observation.

Complaint Investigation MS#25586 was substantiated related to infection control and hand hygiene deficiencies.

The State Agency conducted a Complaint Investigation (CI), MS#25586, related to infection control regarding hand hygiene at the facility on 07/02/2024.

The facility failed to ensure infection control measures were consistently implemented to prevent infection transmission, evidenced by one of four observations of staff improperly handling soiled briefs with gloves in hallways. The facility was cited for noncompliance with infection prevention and control requirements.

The complaint investigation MS#25586 was substantiated related to infection control and hand hygiene violations.

The State Agency conducted a complaint investigation related to call bells not accessible, facility cleanliness, physical environment, and resident grooming.

The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.

Complaint Investigation MS #25030 was related to call bells not accessible, facility not clean, physical environment, and resident not groomed. The complaint was not substantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation (CI), MS #25030, related to call bells not accessible, facility not clean, physical environment, and resident not groomed.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint MS #25030 was investigated related to call bells not accessible, facility not clean, physical environment, and resident not groomed. The complaint was not substantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation (CI MS #24481) at the facility on 3/19/24 regarding pressure sores.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, with no deficiencies cited during this investigation. However, the facility remains out of compliance due to deficiencies cited on the 2/28/2024 survey.

Complaint Investigation (CI MS #24481) was for pressure sores; no deficiencies were cited and the facility was found in compliance during this visit.

The State Agency conducted a Complaint Investigation (CI MS #24481) at the facility on 3/19/24, investigating pressure sores.

The facility was found to be in compliance with Medicare and Medicaid requirements with no deficiencies cited during this investigation; however, the facility remains out of compliance due to deficiencies cited on the 2/28/2024 survey.

Complaint Investigation (CI MS #24481) was for pressure sores and was found to be unsubstantiated with no deficiencies cited.

The State Agency conducted a follow-up revisit at the facility on 3/19/24 related to a complaint survey conducted from 2/26/24 through 2/28/24.

The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and recommends the facility be placed back in compliance effective 3/15/24.

The State Agency conducted a follow-up revisit at the facility on 3/19/24 related to a complaint survey conducted from 2/26/24 through 2/28/24.

The State Agency found the facility to be in compliance with Medicare and Medicaid requirements and recommended the facility be placed back in compliance effective 3/15/24.

The follow-up revisit was related to a complaint survey conducted from 2/26/24 through 2/28/24. The facility was found to be in compliance.

The State Agency conducted two complaint investigations at the facility from 2/26/24 through 2/28/24. One investigation (CI MS #24274) was related to a resident safety incident involving burns from a smoking incident, and the other (CI MS #24301) investigated pressure sores, inappropriate feeding assistance, resident left soiled, and notification of resident representative.

The facility was found not in compliance with state licensure requirements due to failure to provide a safe smoking environment. Specifically, staff failed to remove an oxygen canister and nasal cannula from Resident #1 prior to entering the smoking area and did not secure a cigarette lighter, resulting in Resident #1 sustaining second degree burns to his face. The facility implemented corrective actions including staff inservices and increased supervision during smoking breaks.

Two complaint investigations were conducted. CI MS #24274 was substantiated with a cited deficiency related to resident safety and burns from smoking incident. CI MS #24301 was investigated for pressure sores, inappropriate feeding assistance, resident left soiled, and notification of resident representative, with no deficiencies cited.

The State Agency conducted two complaint investigations at the facility from 2/26/24 through 2/28/24. One investigation (CI MS #24274) was related to a facility reported incident concerning resident safety, and the other (CI MS #24301) was related to pressure sores, inappropriate feeding assistance, resident left soiled, and notification of resident representative.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to implement care plan approaches prohibiting oxygen use in the smoking area, resulting in a resident receiving burns. The facility also failed to provide a safe smoking environment by not removing oxygen canisters and not securing cigarette lighters, leading to a resident sustaining second degree burns to the face.

Two complaint investigations were conducted: CI MS #24274 related to resident safety where deficiencies F656 and F689 were cited, and CI MS #24301 related to pressure sores, inappropriate feeding assistance, resident left soiled, and notification of resident representative with no deficiencies cited.

The State Agency conducted a Complaint Investigation at the facility on 12/20/23 related to Environment issues involving call lights and equipment, and Quality of Care related to incontinent care.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited.

Complaint MS #23542 investigated for Environment (call lights and equipment) and Quality of Care (incontinent care). The complaint was not substantiated as no deficiencies were found.

The State Agency conducted a Complaint Investigation (CI), MS #23542, at the facility on 12/20/23 related to Environment issues involving call lights and equipment, and Quality of Care related to incontinent care.

The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited during the investigation.

Complaint Investigation MS #23542 was substantiated with no deficiencies cited.

The State Agency conducted a Complaint Investigation related to misappropriation of property at the facility.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and no deficiencies were cited.

Investigation MS #23452 was related to misappropriation of property and found no deficiencies.

The State Agency conducted a complaint investigation related to misappropriation of property at the facility.

The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.

Complaint Investigation (CI), MS #23452, related to misappropriation of property; no deficiencies cited.

The State Agency conducted a Complaint Investigation at the facility from 10/24/23 through 10/25/23 related to an allegation of physical abuse.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. There were no deficiencies cited.

Investigation MS #23090 was related to an allegation of physical abuse. The complaint was not substantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation (CI), MS #23090, related to an allegation of physical abuse at the facility from 10/24/23 through 10/25/23.

During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Investigation MS #23090 was related to an allegation of physical abuse; no deficiencies were cited indicating the complaint was not substantiated.

The State Agency conducted a desk review on 08/25/23 of information related to the annual survey conducted on 07/18/23 to confirm corrective measures were implemented.

The facility had put measures in place to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 08/15/23.

The State Agency conducted a desk review on 08/25/23 of information related to the annual survey conducted on 07/18/23 to confirm corrective measures taken by the facility.

The facility had implemented measures to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 08/15/23.

The State Agency conducted a desk review on 08/25/23 of information related to the annual survey conducted on 07/18/23 to confirm corrective measures and compliance with the Life Safety Code.

The facility had implemented measures to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 08/15/23.

The State Agency conducted a desk review on 08/25/23 of information related to the annual survey conducted on 07/18/23 to confirm corrective measures and compliance with the Life Safety Code.

The facility had implemented measures to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 08/15/23.

The State Agency conducted a desk review of information related to the annual survey completed on 07/20/23 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The facility was found to be in compliance with the Minimum Standards of Operation, and the State Agency recommended placing the facility back in compliance effective 08/15/23.

The State Agency conducted a desk review of information related to the annual survey completed on 07/20/23 to verify corrective measures taken by the facility.

The facility provided information confirming that measures were implemented to correct deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 08/15/23.

The State Agency conducted an annual recertification survey at the facility from 7/17/23 through 7/20/23 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with multiple regulatory requirements including resident rights, safe environment, transfer/discharge notice requirements, comprehensive care planning, ADL care, quality of care, respiratory care, medication labeling and storage, and quality assurance program effectiveness.

The State Agency conducted a desk review of information related to the annual survey completed on 07/20/23 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the facility was recommended to be placed back in compliance effective 08/15/23.

The State Agency conducted an Annual Recertification Survey at Lakeview Nursing Center from 7/17/23 to 7/20/23 to determine compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with several standards including residents' rights, activities of daily living, medication labeling and storage, and maintenance of walls and ceilings. Specific deficiencies included failure to provide privacy bags for indwelling catheters, inadequate nail care for a resident, improper medication storage at bedside, and unclean or damaged walls and privacy curtains in resident rooms.

The inspection was conducted to evaluate the facility's compliance with timely transmission of resident assessments as required by federal regulations.

The facility failed to transmit resident assessments in a timely manner for two of twenty resident assessments reviewed, specifically for Residents #51 and #52. The assessments were completed but submitted late, with staff unaware that the transmittals were outside the timely window.

The inspection was conducted to assess compliance with the Life Safety Code (LSC) requirements, specifically focusing on fire alarm system testing and maintenance, and fire drills.

The facility failed to provide current year documentation for the annual inspection of the fire alarm system and did not properly perform or document fire drills for the last calendar year 2022 and the first two quarters of 2023. These deficiencies affected all residents and smoke compartments in the facility.

The inspection was conducted to assess compliance with the Life Safety Code, specifically regarding the maintenance and inspection of the fire alarm system.

The facility failed to provide documentation of the current year (2023) annual inspection of the fire alarm system, affecting all 82 residents. The deficiency was acknowledged by the Administrator and Maintenance Supervisor.

The survey was conducted to assess the facility's compliance with emergency preparedness requirements.

The facility met all applicable Federal, State, and local emergency preparedness requirements during the survey.

The State Agency conducted a desk review related to a complaint survey completed on 2023-05-31 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the facility was recommended to be placed back in compliance effective 2023-06-13.

The visit was complaint-related, reviewing information from a complaint survey completed on 2023-05-31. The facility was found in compliance and the complaint was effectively resolved.

The State Agency conducted a desk review related to a complaint survey completed on 2023-05-31 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2023-06-13.

The visit was complaint-related, reviewing corrective actions following a complaint survey completed on 2023-05-31. The facility's corrective measures were confirmed and compliance was recommended.

The State Agency conducted a Complaint Investigation at the facility from 6/19/23 through 6/20/23 related to insufficient linens, low staffing, water not offered to residents, infection control policy, roaches in facility, equipment not maintained, food cold, employee to resident abuse, improper incontinence care, and resident not treated with respect.

No deficiencies were cited during the complaint investigation; however, the facility remains out of compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement.

The complaint investigation involved allegations of insufficient linens, low staffing, water not offered to residents, infection control policy issues, roaches in the facility, equipment not maintained, food served cold, employee to resident abuse, improper incontinence care, and residents not treated with respect. No deficiencies were cited.

The State Agency conducted a complaint investigation at the facility from 6/19/23 through 6/20/23 related to issues including insufficient linens, low staffing, water not offered to residents, infection control policy, roaches in facility, equipment not maintained, cold food, employee to resident abuse, improper incontinence care, and resident not treated with respect.

No deficiencies were cited during the complaint investigation; however, the facility remains out of compliance due to deficiencies cited on the 5/31/23 survey.

The complaint investigation covered allegations of insufficient linens, low staffing, water not offered to residents, infection control policy issues, roaches in the facility, equipment not maintained, cold food, employee to resident abuse, improper incontinence care, and resident not treated with respect. No deficiencies were cited during this investigation.

The State Agency conducted multiple Complaint Investigations at the facility from 5/16/2023 through 5/31/2023 due to complaints including elopement, verbal abuse by staff, medication error, resident assessment/neglect, and resident-on-resident abuse.

The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies included failure to prevent verbal abuse by staff toward a resident and failure to provide adequate supervision to prevent elopement of a resident with known wandering risk. Immediate Jeopardy was identified related to elopement but was removed after corrective actions. The facility implemented corrective actions including staff in-services, updated care plans, window modifications, and monitoring procedures.

The complaint investigations included multiple MS numbers related to resident assessment/neglect, resident-on-resident abuse, accidents due to falls, medication error, verbal abuse by staff, and elopement. Some complaints were substantiated with cited deficiencies (verbal abuse and elopement), while others were not.

The State Agency conducted multiple Complaint Investigations at Lakeview Nursing Center from 5/16/2023 through 5/31/2023 due to various complaints including resident assessment/neglect, resident-on-resident abuse, accidents due to falls, medication errors, verbal abuse by staff, and elopement incidents.

The facility was found not in compliance with state licensure requirements. No deficiencies were cited for resident assessment/neglect, resident-on-resident abuse, falls, or medication errors. Deficiencies were cited for verbal abuse by staff and failure to prevent elopement of a resident with known wandering risk. An Immediate Jeopardy was identified related to elopement but was removed after corrective actions. The facility implemented corrective actions including staff training, supervision, environmental modifications, and monitoring procedures.

The complaint investigations included multiple complaint numbers (MS #21516, MS #21548, MS #21562, MS #21563, MS #21567, MS #21584, MS #21668, MS #21677). The investigations related to resident assessment/neglect, resident-on-resident abuse, falls, and medication errors found no deficiencies. The investigation of verbal abuse by staff resulted in a Level II deficiency (M500). The investigation of elopement resulted in a Level IV deficiency (M640) and an Immediate Jeopardy that was removed after corrective actions.

The State Agency conducted a follow-up revisit at the facility on 5/11/23 related to the complaint survey conducted from 3/28/23 through 3/31/23.

The State Agency found the facility to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, recommending the facility be placed back in compliance effective 5/9/23.

The revisit was related to a complaint survey conducted from 3/28/23 through 3/31/23. The facility was found to be in compliance upon follow-up.

The State Agency conducted a follow-up revisit at the facility on 5/11/23 related to the complaint survey conducted from 3/28/23 through 3/31/23.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 5/9/23.

Follow-up visit related to a prior complaint survey conducted 3/28/23 through 3/31/23; facility found in compliance.

The State Agency conducted an on-site Complaint Investigation from 03/28/23 to 03/31/23 due to allegations of neglect related to failure to prevent constipation in Resident #1, which resulted in the resident's death.

The facility failed to document and monitor bowel movements for five sampled residents, including Resident #1, whose untreated constipation led to bowel impaction, hospitalization, and death. The facility was found to have inadequate documentation practices, failure to follow bowel care policies, and lack of proper supervision of nursing staff. Immediate Jeopardy was identified and later removed after corrective actions and staff in-services were implemented.

The complaint investigation revealed Immediate Jeopardy and Substandard Quality of Care beginning 03/02/23 when Resident #1 began vomiting and complaining of stomach pain, was hospitalized on 03/02/23, and died on 03/03/23 due to aspiration from vomiting caused by bowel impaction. The facility failed to monitor and document bowel movements, leading to neglect.

The State Agency conducted an on-site Complaint Investigation from 03/28/23 to 03/31/23 due to allegations of neglect related to bowel management and care planning.

The facility failed to properly monitor and document bowel movements for five sampled residents, resulting in neglect that led to Resident #1's bowel impaction, hospital admission, and death. The facility also failed to implement care plans and provide necessary treatments, and lacked adequate administrative oversight and staff supervision.

The visit was triggered by complaints regarding neglect related to bowel management and failure to provide necessary care, which resulted in Resident #1's death due to bowel impaction and aspiration.

The State Agency conducted a Complaint Investigation (CI), MS #20416 at the facility on 1/12/23 related to allegations of abuse.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. The complaint was not substantiated and no deficiencies were cited.

Complaint MS #20416 related to abuse was investigated and not substantiated.

The State Agency conducted a complaint investigation (MS #20416) related to resident abuse at the facility on 01/12/2023.

The facility was found to be in compliance with Medicare and Medicaid participation requirements. The complaint related to resident abuse was not substantiated and no deficiencies were cited.

Complaint related to resident abuse was investigated and not substantiated.

The State Agency conducted a Complaint Investigation at the facility from 12/13/22 through 12/15/22 related to allegations including sexual abuse, staffing, resident neglect, resident falls, infection control, and dietary services.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. The complaints were not substantiated and no deficiencies were cited.

The complaint investigation involved MS #20109 and MS #20133. MS #20109 for sexual abuse was not substantiated. MS #20133 related to staffing, resident neglect, sexual abuse, resident falls, infection control, and dietary services was also not substantiated.

The State Agency conducted a Complaint Investigation at the facility from 12/13/22 through 12/15/22 related to allegations including sexual abuse, staffing, resident neglect, resident falls, infection control, and dietary services.

The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints were not substantiated and no deficiencies were cited.

The complaint investigation included CI MS #20109 for sexual abuse and CI MS #20133 related to staffing, resident neglect, sexual abuse, resident falls, infection control, and dietary services. Neither complaint was substantiated.

The State Agency conducted a desk review of information related to a complaint survey completed on 2022-10-19 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.

The visit was complaint-related, reviewing a complaint survey from 2022-10-19. The facility was found to be in compliance.

The State Agency conducted a desk review related to a complaint survey completed on 2022-10-19 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 2022-11-15.

Visit was complaint-related; the desk review confirmed corrective measures were in place and compliance was restored.

The State Agency conducted a desk review related to a complaint survey that was completed on 2022-10-19.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.

The complaint survey was completed on 2022-10-19 and the desk review on 2022-11-22 confirmed the facility was in compliance.

The State Agency conducted a desk review related to a complaint survey completed on 2022-10-19 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficiencies and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2022-11-15.

The visit was complaint-related, reviewing corrective actions following a complaint survey conducted on 2022-10-19. The facility's corrective measures were confirmed and found satisfactory.

The State Agency conducted a Complaint Investigation at the facility from 10/17/22 through 10/19/22 based on complaint numbers MS #19594 and #19674.

The facility was found to be in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm, and no deficiencies were cited.

Complaint Investigation MS #19594 and #19674 was conducted and found to be unsubstantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation at the facility from 10/17/22 through 10/19/22.

The facility was found to be in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm and no deficiencies were cited.

Complaint Investigation MS #19594 and #19674; no deficiencies cited indicating compliance.

The State Agency conducted a Complaint Investigation and a COVID-19 Focused Infection Control survey at the facility from 10/17/22 through 10/19/22. The complaint investigation was triggered by MS #19674 and MS #19594.

The facility was found to be in compliance with infection control regulations and CMS/CDC recommended COVID-19 practices with no deficiencies cited for infection control. The complaint MS #19594 was not substantiated, but MS #19674 was substantiated with a citation for a Physician Order transcription error affecting two residents.

Complaint Investigation MS #19674 was substantiated related to a Physician Order transcription error. Complaint MS #19594 related to infection control, grooming, and staffing was not substantiated.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency at the facility from 10/17/22 through 10/19/22.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.

The State Agency conducted a Complaint Investigation at the facility from 10/17/22 through 10/19/22 based on complaint numbers MS #19594 and #19674.

The facility was found to be in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm, and no deficiencies were cited.

Complaint Investigation MS #19594 and #19674; no deficiencies cited indicating the complaints were not substantiated.

The State Agency conducted a Complaint Investigation and a COVID-19 Focused Infection Control survey at the facility from 10/17/22 through 10/19/22. The complaint investigation was triggered by MS #19674 and MS #19594.

The facility was found to be in compliance with infection control regulations and CMS/CDC COVID-19 practices with no deficiencies cited for infection control. The complaint MS #19594 was not substantiated, but MS #19674 was substantiated with a citation for a Physician Order transcription error affecting two residents.

Complaint Investigation involved MS #19674 and MS #19594. MS #19594 was not substantiated related to infection control, grooming, and staffing. MS #19674 was substantiated for a Physician Order transcription error.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency at the facility from 10/17/22 through 10/19/22.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency at the facility from 10/17/22 through 10/19/22.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency at the facility from 10/17/22 through 10/19/22.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The State Agency conducted a Complaint Investigation at the facility related to allegations of neglect, abuse, and failure to notify the Responsible Representative of resident change in condition.

The complaint was not substantiated, and the facility was found to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited.

Complaint Investigation MS #19240 regarding neglect, abuse, and Responsible Representative not notified of resident change in condition was not substantiated.

The State Agency conducted a complaint investigation at the facility on 7/5/22 regarding allegations of neglect, abuse, and failure to notify the responsible representative of changes.

The complaint was not substantiated and no deficiencies were cited during this investigation. However, the facility remains out of compliance due to deficiencies cited in a prior complaint investigation on May 11, 2022.

Complaint investigation MS #19240 was conducted; the complaint for neglect, abuse, and failure to notify the responsible representative was not substantiated.

The State Agency conducted a follow-up revisit survey at the facility on 7/5/22 to verify compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

During the follow-up survey, the facility was found to be in compliance with the applicable state regulations and licensure requirements.

The State Agency conducted a follow-up revisit at the facility on 7/5/22 related to the complaint survey conducted 5/9/22 through 5/11/22.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 6/28/22.

Follow-up visit related to a prior complaint survey conducted 5/9/22 through 5/11/22; facility found in compliance.

The State Agency conducted a Complaint Investigation (CI), MS #18775 at the facility from 2022-05-09 to 2022-05-11.

During the survey, the State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements.

Complaint Investigation MS #18775 was conducted and the facility was found to be in compliance.

The State Agency conducted a Complaint Investigation (CI) MS #18775 at the facility from 5/9/22 to 5/11/22 due to a complaint regarding the facility's failure to provide care in accordance with the physician's orders.

The facility was found not in compliance with Medicare and Medicaid requirements, specifically failing to follow the comprehensive care plan and physician's orders for one resident, resulting in medication errors related to Lexapro dosage administration.

The complaint was substantiated regarding the facility's failure to provide care in accordance with the physician's orders, specifically involving medication errors for Resident #1 related to Lexapro dosage.

The State Agency conducted a Complaint Investigation (CI) MS #18746 and MS #18757 at the facility from 2022-05-03 to 2022-05-04.

During the survey, the State Agency determined the facility was in compliance with the Requirements for Institutions for the Care of the Aged or Infirm.

Complaint Investigation MS #18746 and MS #18757; facility found in compliance.

The State Agency conducted a complaint investigation at the facility from 2022-05-03 to 2022-05-04 based on complaints regarding nurse care, residents left wet, facility cleanliness, and call light response.

The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints were not substantiated and no deficiencies were cited.

The complaint investigation involved MS #18746 and MS #18757. The complaint regarding a nurse not rendering care and residents left wet, facility cleanliness, and call lights not being answered were not substantiated.

The State Agency conducted a Complaint Investigation at the facility from 3/1/22 through 3/3/22 regarding multiple complaints including call bell not answered, abuse, injury, and wound care.

The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints were not substantiated and no deficiencies were cited.

Complaints investigated included call bell not answered, abuse, injury, and wound care. None were substantiated.

The State Agency conducted a Complaint Investigation at the facility from March 1, 2022 through March 3, 2022, in response to complaints regarding call lights not being answered, abuse, injury, and wounds.

The State Agency did not substantiate the complaints and determined the facility was in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited.

Complaints investigated included call lights not being answered, abuse, injury, and wounds; none were substantiated.

The State Agency conducted a follow-up/revisit survey on 11/30/2021 for a complaint survey that was conducted from 9/20/2021 through 9/24/2021.

During the survey, the State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.

The visit was a follow-up to a complaint survey conducted from 9/20/2021 through 9/24/2021. The facility was found to be in compliance during the follow-up.

The State Agency conducted a follow-up/revisit survey on 11/30/2021 for a complaint survey conducted 9/20/2021 through 9/24/2021.

During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid effective 11/23/2021.

The visit was a follow-up to a complaint survey conducted from 9/20/2021 to 9/24/2021. The facility was found in compliance during this revisit.

The State Agency conducted a Complaint Investigation (CI) MS #18267 at the facility on 11/29/21.

The State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.

Complaint Investigation MS #18267 was conducted and the facility was found in compliance.

The State Agency conducted a complaint survey at the facility for Complaint Investigation (CI) MS #18267 for Infection Control on 11/29/21.

During the survey, the facility was found to be in compliance with the requirements for participation in Medicare and Medicaid. The complaint was not substantiated and no deficiencies were cited.

Complaint Investigation (CI) MS #18267 for Infection Control; complaint was not substantiated.

A complaint investigation (CI MS #18195) was conducted at the facility by the State Agency on 10/26/21 based on a facility reported incident.

The complaint investigation was not substantiated. The facility remains out of compliance due to deficiencies cited on a previous survey dated 9/24/2021.

Complaint Investigation (CI MS #18195) was not substantiated.

A complaint investigation (CI MS #18195) was conducted at the facility by the State Agency on 10/26/21 based on a facility reported incident.

The complaint investigation was not substantiated. The facility remains out of compliance due to deficiencies cited on a previous survey dated 9/24/2021.

Complaint Investigation (CI MS #18195) was not substantiated and was based on a facility reported incident with a thorough investigation conducted by the facility.

The State Survey Agency conducted six complaint investigations at the facility from 09/20/2021 to 09/24/2021, triggered by allegations including pressure ulcers, medication diversion, incontinent care, and failure to prevent ant bites.

The facility was found non-compliant with state licensure requirements, substantiating complaints related to pressure ulcers, medication diversion, untimely incontinent care, and failure to prevent ant bites. Deficiencies included failure to provide timely incontinent care resulting in a Stage I pressure injury, diversion of medication for five residents, inadequate bathing and incontinence care for multiple residents, and presence of ants causing resident harm.

Six complaint investigations were conducted (CI #17522, #17852, #18016, #18047, #18048, #18077). The SSA substantiated complaints for pressure ulcers (#17852), medication diversion (#18016), untimely incontinent care (#18048), and failure to prevent ant bites (#18077). Complaints for infection control and social distancing (#17522) and physician orders/notification (#18047) were unsubstantiated.

The State Survey Agency conducted six complaint investigations at the facility from 9/20/21 to 9/24/21, triggered by multiple complaints regarding pressure ulcers, medication diversion, incontinent care, and ant bites.

The facility was found non-compliant with Medicare and Medicaid participation requirements, substantiated for pressure ulcers, medication diversion, failure to provide timely incontinent care, and failure to prevent ant bites. Deficiencies were cited related to grievances, abuse and neglect, misappropriation of medication, care planning, ADL care, pressure ulcer prevention and treatment, and accident hazards.

The complaint investigations substantiated issues including pressure ulcers, medication diversion, failure to provide timely incontinent care, and failure to prevent ant bites. Some complaints related to infection control and physician order notification were unsubstantiated.

The State Agency conducted a complaint survey from 5/5/21 through 5/7/21 to investigate complaint MS #17788 regarding abuse, unqualified staff, no pressure sore prevention, no rehabilitation services, and dead termites in the window sill.

The survey was unable to substantiate complaint MS #17788 and determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm.

Complaint MS #17788 was investigated for abuse, unqualified staff, no pressure sore prevention, no rehabilitation services, and dead termites in the window sill; the complaint was not substantiated.

The State Agency conducted a complaint survey from 5/5/21 through 5/7/21 to investigate complaint MS #17788 regarding abuse, unqualified staff, no pressure sore prevention, no rehabilitation services, and dead termites in the window sill.

During the survey, the State Agency was unable to substantiate the complaint and determined the facility was in compliance with Medicare and Medicaid participation requirements.

Complaint MS #17788 was investigated for abuse, unqualified staff, no pressure sore prevention, no rehabilitation services, and dead termites in the window sill; the complaint was not substantiated.

The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).

The facility failed to report complete COVID-19 information to the NHSN during a seven-day period from 04/12/2021 to 04/18/2021 as required by regulation, potentially causing more than minimal harm to residents.

The facility was inspected due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network as required by regulation.

The facility failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day period between 04/05/2021 and 04/11/2021, which has the potential to cause more than minimal harm to all residents.

The State Agency conducted a COVID-19 Focused Survey along with two complaint investigations (CI MS #17301, CI MS #17496) at the facility on 1/23/2021.

The facility was found to be in compliance with the Minimum Standards for State Licensure Requirements for nursing homes. Complaint investigations #17301 and #17496 were not substantiated.

CI #17301 was not substantiated for medical records (accident report) not being released to resident representative. CI #17496 was not substantiated for neglect.

A COVID-19 Focused Infection Control Survey and two Complaint Investigations (CI MS #17301 and CI MS #17496) were conducted due to concerns about infection control compliance and specific complaints.

The facility was found non-compliant with infection control regulations, including failure to follow PPE protocols, lack of a trained Infection Control Preventionist, and ineffective QAPI program during three COVID-19 outbreaks. An Immediate Jeopardy was identified and later removed after corrective actions. Both complaint investigations were not substantiated.

Complaint Investigation #17301 was not substantiated for medical records not being released to resident representative. Complaint Investigation #17496 was not substantiated for neglect.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 1/19/21 through 1/23/21.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.

A COVID-19 Focused Infection Control Survey and two Complaint Investigations were conducted due to concerns about infection control and compliance with COVID-19 guidelines.

The facility failed to follow infection control guidelines including improper use of PPE, failure to have a certified Infection Preventionist prior to survey, inadequate Quality Assurance and Performance Improvement (QAPI) program, and contamination risks such as laundry on the floor. These failures led to multiple COVID-19 outbreaks with 89 residents and 68 staff testing positive and nine resident deaths.

Two complaint investigations (CI MS #17301 and CI MS #17496) were conducted; neither was substantiated for the allegations of medical records release or neglect.

The State Agency conducted a COVID-19 Focused Survey along with two complaint investigations (CI MS #17301, CI MS #17496) at the facility on 1/23/2021.

The facility was found to be in compliance with the Minimum Standards for State Licensure Requirements for nursing homes. Complaint investigations #17301 and #17496 were not substantiated.

CI #17301 was not substantiated for medical records (accident report) not being released to resident representative. CI #17496 was not substantiated for neglect.

A COVID-19 Focused Infection Control Survey and two Complaint Investigations were conducted due to concerns about infection control and compliance with COVID-19 guidelines.

The facility failed to follow infection control guidelines including improper use of PPE, failure to have a certified Infection Preventionist on staff, inadequate Quality Assurance and Performance Improvement (QAPI) program, and contamination risks such as laundry on the floor. These deficiencies led to multiple COVID-19 outbreaks with 89 residents and 68 staff testing positive and nine resident deaths.

Two complaint investigations (CI MS #17301 and CI MS #17496) were conducted; neither was substantiated for the allegations of medical records not being released or neglect.

A COVID-19 Focused Infection Control Survey along with a complaint investigation (CI MS #17145) was conducted by the State Agency.

The facility was found to be in compliance with infection control regulations and implemented recommended COVID-19 practices. The complaint investigation was unsubstantiated with no deficiencies cited related to Quality of Care, Responsible Party Notified, or Resident Neglect.

Complaint investigation CI MS #17145 was unsubstantiated with no deficiencies cited for Quality of Care related to Responsible Party Notified and Resident Neglect.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

A COVID-19 Focused Infection Control Survey along with a complaint investigation (CI MS #17145) was conducted by the State Agency.

The facility was found to be in compliance with infection control regulations and implemented recommended COVID-19 practices. The complaint investigation was unsubstantiated with no deficiencies cited related to Quality of Care, Responsible Party Not Notified, or Resident Neglect.

Complaint investigation CI MS #17145 was unsubstantiated with no deficiencies cited for Quality of Care related to Responsible Party Not Notified and Resident Neglect.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.

A COVID-19 Focused Infection Control Survey along with complaint investigations (CI MS #16724 and CI MS #16753) were conducted by the State Agency on 09/17/2020.

The facility was found to be in compliance with infection control regulations and CDC recommended practices for COVID-19. Both complaint investigations were unsubstantiated with no deficiencies cited related to Residents Rights or Quality of Care.

Two complaint investigations (CI MS #16724 and CI MS #16753) were conducted; both were unsubstantiated with no deficiencies cited.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

A COVID-19 Focused Infection Control Survey along with a complaint investigation was conducted by the State Agency on 9/17/2020.

The facility was found to be in compliance with infection control regulations and implemented recommended COVID-19 practices. Two complaint investigations conducted on 9/17/2019 were unsubstantiated with no deficiencies cited.

Two complaint investigations (CI MS #16724 and CI MS #16753) were conducted; both were unsubstantiated with no deficiencies cited for Residents Rights or Quality of Care related to Client Services Not Performed Per Physician Orders.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 8/4/2020.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/4/2020 to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 7/1/20 to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 7/1/20 to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

The State Agency conducted a complaint survey at the facility from 12/18/19 to 12/31/19 for three complaint investigations (CI MS #16447, #16472, and #16466). The survey was triggered by complaints related to careplans, pain management during pressure ulcer wound care, falls, incontinent care, and staffing.

The survey substantiated complaints related to careplans, pain management during pressure ulcer wound care, and falls, identifying harm levels. The facility failed to assess pain levels before wound care for Resident #4 and failed to provide adequate supervision for Resident #7, who fell and sustained a fractured hip due to improper monitoring of a self-release safety belt. The facility was found not in compliance with Minimum Standards and cited for deficiencies.

The complaint survey was conducted for CI MS #16447, #16472, and #16466. The agency substantiated CI MS #16447 and #16472 related to careplans, pain management during pressure ulcer wound care, and falls. CI MS #16466 related to incontinent care and staffing was not substantiated.

The State Agency initiated a complaint survey on 12/17/19 and completed it on 12/31/19, investigating allegations related to quality of care, pain management during pressure ulcer care, infection control, supervision related to falls, incontinent care, and staffing.

The survey substantiated deficiencies related to failure to assess and manage pain during wound care for Resident #4, inadequate supervision and monitoring of Resident #7's self-release belt leading to a fall and hip fracture, and infection control lapses including improper placement of soiled linen and trash and lack of contact isolation signage and PPE supplies. The facility was found not in compliance with Medicare and Medicaid participation requirements.

The complaint investigation was initiated for CI MS #16447, CI MS #16472, and CI MS #16466. The survey substantiated allegations related to quality of care, pain management, infection control, and supervision related to falls. One complaint related to incontinent care and staffing was not substantiated.

The State Agency conducted an annual recertification along with a complaint survey from 9/16/2019 to 9/19/2019 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with several requirements including resident grievance resolution, posting of survey results, timely transmission of Minimum Data Set (MDS) assessments, and prevention of unnecessary drug use. No citations were related to the complaint investigations.

Complaint investigations for pressure ulcer neglect and death prevention were not substantiated and no citations were related to the complaints.

The State Agency conducted an annual recertification along with a complaint survey from 9/16/2019 to 9/19/2019 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with Medicare and Medicaid requirements, with citations issued for resident/family group response, right to survey results, encoding/transmitting resident assessments, unnecessary drug use, infection prevention and control, cooking facilities, fire drills, and electrical systems. Complaints related to pressure ulcer neglect and death prevention were not substantiated.

Complaint investigations for pressure ulcer neglect and death prevention were not substantiated with no citations related to the complaint.

The inspection was conducted to review compliance with Life Safety Code requirements, specifically focusing on documentation of annual generator testing as required by NFPA 99.

The facility failed to properly document records of monthly load tests and weekly inspections of the generator for the years 2018 and 2019, which could potentially affect the entire facility.

A complaint investigation was conducted at the facility on April 11, 2019.

The investigation was unsubstantiated with no deficiencies cited.

Investigation was unsubstantiated with no deficiencies cited.

The State Agency conducted a partial extended survey for Complaint Investigation MS #15614 from 1/14/19 to 1/23/19, substantiating the complaint for elopement of Resident #1.

The facility was found not in compliance with Medicare and Medicaid participation requirements, with an Immediate Jeopardy and Substandard Quality of Care related to inadequate supervision and failure to investigate and report the elopement of a confused, demented resident. The facility failed to notify responsible parties and state agencies timely and did not ensure adequate supervision to prevent elopement, placing residents at risk of serious injury or death.

Complaint investigation substantiated for elopement of Resident #1. Immediate Jeopardy and Substandard Quality of Care were identified related to supervision and reporting failures. The facility submitted an acceptable Allegation of Compliance and removed the Immediate Jeopardy on 1/19/19.

A complaint investigation was conducted on January 10, 2019 in the facility.

The result of the investigation was unsubstantiated with no deficiencies cited.

Complaint investigation was unsubstantiated with no deficiencies cited.

A complaint investigation was conducted at Lakeview Nursing Center on August 14, 2018.

The investigation was unsubstantiated with no deficiencies cited.

The complaint investigation was unsubstantiated with no deficiencies cited.

A complaint investigation was conducted at the facility on 2/20/18.

The investigation was unsubstantiated with no deficiencies cited.

Complaint investigation was unsubstantiated with no deficiencies cited.

The State Agency conducted an annual survey along with a complaint investigation from 10/16/17 to 10/19/17. The complaint investigation was unsubstantiated with no deficiencies related to the complaints.

During the annual recertification survey, the facility was found not in compliance with State Licensure Regulations for the Aged or Infirm, specifically related to criminal history record checks for employees. The facility failed to implement proper screening methods for new hires, including incomplete background and reference checks for one new hire.

The complaint investigation was unsubstantiated with no deficiencies cited related to the complaints.

The State Agency conducted an annual survey along with a complaint investigation from 10/16/17 to 10/19/17. The complaint investigation was unsubstantiated with no deficiencies related to the complaints. The annual recertification survey found the facility not in compliance with Medicare and Medicaid requirements.

The survey cited deficiencies related to new hire screening procedures, infection control practices including glucometer cleaning and eye drop administration, and failure to designate a hospice coordinator. The complaint investigation was unsubstantiated with no deficiencies related to the complaints.

Complaint investigation was unsubstantiated with no deficiencies cited related to the complaints.

A desk review was conducted on 2/24/17 to assess the facility's compliance status.

The facility was found to be in substantial compliance effective 2/23/17 with no deficiencies noted in the report.

A desk review was conducted on 2/24/17 to assess the facility's compliance status.

The facility was found to be in substantial compliance effective 2/23/17 with no deficiencies cited in this report.